Cytoreduction, Peritonectomy and Hyperthermic Antiblastic Peritoneal Perfusion for the Treatment of Peritoneal Carcinomatosis
Michele De Simone* and Marco Vaira
About this Chapter
Peritoneal carcinomatosis may present as synchronous disease or like evolution of
gastrointestinal or female genital tumors (including pseudomyxoma peritonei, a variable
malignancy myxoid tumor, arising from the appendix). It is also the common way of presentation of primitive peritoneal tumors (like peritoneal mesothelioma). Peritoneal carcinomatosis has been considered nearly impossible to treat with surgery till few years ago. Moreover, the results obtained with systemic chemotherapy were poor. In the ‘80s, some authors developed and improved a new combined technique to manage peritoneal carcinomatosis, consisting in cytoreduction of neoplastic lesions, peritonectomy (removal of peritoneum macroscopically affected from tumor) and hyperthermic antiblastic peritoneal perfusion (H.A.P.P.). Carcinomatosis nodes usually affects peritoneum in preferential sites as the pelvis, the ileum-caecal angle, the right diaphragm and retrohaepatic space, the lesser omentum, the left diaphragm and paracolic spaces. In fact, in these regions the peristalsis is less effective, there are the points of peritoneal fluid absorbtion and, finally, these areas are particularly anfractuous, with virtual spaces, so the circulation of fluids is slow and neoplastic cells may easily lodge. At least, cells may deposit under action of the force of gravity. For these reasons, peritonectomy is particularly indicated in these regions. The rationale of combining hyperthermia and chemotherapy has been described in previous chapters. The peritoneal cavity can be considered a “pharmacological sanctuary” for the presence of the peritoneal-plasmatic barrier, that is independent from mesothelial layer, and preserves the leakage to systemic circulation of high molecular weight drugs as Cisplatinum, C-Mytomicin, Doxorubicin, Oxaliplatinum. So it’s possible the use of an high concentration of cytostatic drugs into the tumor area, with mild side-effects. The H.A.P.P. has maximal efficacy when all the macroscopic disease has been removed with cytoreduction and peritonectomy. There is loss of efficacy on nodules bigger than 3 mm, because this is the maximal depth that the drugs can reach, even in hyperthermic condition.